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Introduction Venous sinus stenting (VSS) has emerged as a treatment option for idiopathic intracranial hypertension (IIH) in patients with venous sinus stenosis, whereas cerebrospinal fluid (CSF) shunting remains the traditional surgical approach for refractory disease. Comparative evidence between these strategies remains limited.Material and Methods We performed a systematic review and meta-analysis of studies comparing VSS and CSF shunting for IIH. PubMed, Embase, and Cochrane databases were searched from inception through March 2026. Studies reporting comparative outcomes between both treatments were included. Primary outcomes were headache improvement, residual papilledema after treatment, acetazolamide reduction or discontinuation, and repeat intervention. Random-effects models were used to calculate pooled odds ratios (OR) with 95% confidence intervals (CI).Results Five comparative studies including 7,006 patients met inclusion criteria. A total of 1,471 patients underwent VSS and 5,536 underwent CSF shunting. VSS was associated with a lower prevalence of residual papilledema compared with CSF shunting (OR 0.80; 95% CI 0.71-0.90; p=0.009; I2=0%; figure 2). No significant differences were observed for headache improvement (OR 2.25, 95% CI 0.97-5.23; p=0.06), acetazolamide reduction or discontinuation (OR 0.49, 95% CI 0.08-2.92; p=0.44), or repeat intervention (OR 0.45, 95% CI 0.13-1.54; p=0.20). Sensitivity analyses demonstrated consistent results.Conclusions In this meta-analysis of comparative studies, venous sinus stenting was associated with a lower prevalence of residual papilledema than those undergoing CSF shunting, while other clinical outcomes were similar. These findings support VSS as a physiologically targeted treatment option in appropriately selected patients with IIH, although prospective comparative studies are needed to define optimal treatment strategies.Disclosures G. Mantovani: None. R. Rodrigues: None. S. Pandey: None. V. Pereira: None.Abstract E-243 Figure 1Abstract E-243 Figure 2